Policy Statement
Procedure codes submitted with modifier 22 may be eligible for increased reimbursement to the extent they follow these guidelines:
- The procedure code must have a global day indicator of 0, 10 or 90 in the current version of the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule Relative Value File. Our health plan may establish a global period for surgical procedures if none has been established by CMS and CMS has not determined whether a global period is inappropriate. And;
- For all services other than global maternity care, documentation must indicate that the procedure required substantially greater work than usually required. Example of substantially greater work includes, but is not limited to, two or more of the following factors:
- Unusual lengthy procedure.
- Excessive blood loss during the procedure.
- Trauma is extensive enough to complicate the procedure and cannot be billed with separate procedure code.
- Other pathologies, tumors or malformations (i.e. genetic, traumatic or surgical) that directly interfere with the procedure but cannot be billed with separate procedure codes.
- The service rendered is significantly more complex than described for the submitted CPT or HCPCS code and a secondary procedure cannot be reported for the additional work.
- For maternity services, modifier 22 is appropriate when any one of the following are met:
- Cesarean delivery of twins is performed and only code 59510 is reported.
- Delivery of a singleton requiring a degree of difficulty above what is considered normal (e.g. Vacuum assisted delivery, Severe hypertension/preeclampsia, Maternal sepsis, Hemorrhage, etc.) and only the delivery code is reported.
- The entire global maternity period (antenatal care, labor/delivery and postpartum care) is complicated and necessitates greater effort than typically required and a global maternity code is reported.
For complications or conditions unrelated to the pregnancy, refer to Policy Cross References, Maternity Care (Med107).
When billing a global maternity code and there is a repair of third- or fourth-degree lacerations at the time of delivery, the repair may be reported by using a CPT code from the Integumentary section (e.g., 12041, 12042, 12044-12047 or 13131-13133). Or, if billing the delivery only code, modifier 22 may be added to report the repair.
To be considered for increased reimbursement, documentation from the patient’s record supporting the significantly greater effort must be submitted with the claim. It is not enough to simply document the extent of the patient’s illness or comorbid conditions causing additional work. The documentation must describe additional work performed (e.g. increased intensity, technical difficulty of procedure, severity of patient’s condition, etc.).
When a provider reports an eligible procedure with modifier 22 appended, reimbursement will be 120% of the established fee. Reduction for multiple procedures, bundling and other clinical edits will still apply.
Modifier 22 is not appropriate for use in the following circumstances:
- If the sole purpose for use of the modifier is for a complication due to the surgeon’s choice of approach.
- For example, the surgeon has elected a vaginal approach for a hysterectomy which resulted in additional work that would not have been considered an ‘unusual procedural service’ or additional work greater than what is required for an abdominal hysterectomy. The additional work due to the vaginal approach does not warrant increased reimbursement.
- If the additional work or procedure is considered a component of the primary procedure or another procedure performed in the same operative session and is not separately reimbursable.
- For example: If there is an average amount of lysis or division of adhesions between the organs and adjacent structures. The lysis of adhesions is considered a component of the primary procedure performed.
- If the sole purpose for use of the modifier is due to a ‘reoperation’ where the patient has had a prior surgery but does not significantly increase the difficulty of the current surgery.
- If another code exists which more appropriately defines the services provided.
- If the code is an Evaluation and Management (E/M) service.
- If the code is an anesthesia code. For anesthesia codes, the anesthesia physical status modifiers may be appended to indicate additional effort and complexity of the procedure.
- If the code is a laboratory code.
- If the sole purpose for use of the modifier is due to the use of robotic-assisted, computer assisted navigational device or other specialized techniques (e.g., laparoscope, laser). Modifier 22 may be used to report substantial additional work that occurred during the surgical procedure unrelated to the use of the robotic-assisted, computer assisted navigational device or other specialized techniques and meets the guidelines outlined in this policy.
- If the level of experience and training of the surgeon performing the procedure increases the operative time.
- If the provider reports extended/increased post-operative time.
- If the provider reports unlisted or non-specific procedural codes.
Modifiers 22 and 63 cannot be billed on the same procedure code.
For surgeries or procedures partially reduced or the services performed are significantly less than usually required, refer to Policy Cross References, Modifier 52; Reduced Services.
References
Cross References
- Adm 101 – Global Days
- Ane 102 – Anesthesia Reimbursement & Services Reporting – Group and Individual
- Med 107 – Maternity Care
- Mod 110 – Modifier 63; Procedures Performed on Infants Less Than 4kg
- Mod 115 – Modifier 52; Reduced Services
